Provider Demographics
NPI:1982730438
Name:STOVALL, JERRY (LCSW)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:STOVALL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2485 OLD EUREKA WAY
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0336
Mailing Address - Country:US
Mailing Address - Phone:530-242-8971
Mailing Address - Fax:530-244-1546
Practice Address - Street 1:2485 OLD EUREKA WAY
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0336
Practice Address - Country:US
Practice Address - Phone:530-242-8971
Practice Address - Fax:530-244-1546
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS163191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACSW163190Medicaid
CACSW163190Medicaid